Health inspection·February 20, 2020

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure a resident with a percutaneous endoscopic gastrostomy (PEG) tube had appropriate care and services provided during medication administration This affected one resident (Resident #21) out of five residents reviewed for unnecessary medications. Findings Included: Record review revealed Resident #21 was admitted to the facility with diagnoses including cerebral infarction, protein calorie malnutrition, flaccid hemiplegia, hypovolemic shock, and metabolic encephalopathy. According to this resident's Minimum Data Set assessment dated [DATE] this resident had severe cognitive impairment. Functionally he needed extensive assistance of two people for bed mobility and transfers. He was totally dependent on staff for eating, toileting and personal hygiene. On 02/19/20 at 11:00 A.M. observation revealed Licensed Practical Nurse (LPN) #605 preparing medications to give to Resident #21. Observation revealed this LPN put two Tylenol 500 milligrams and a verapamil tablet of 160 mg into a plastic envelope and crush them together. She then proceeded to place the crushed medications in a small medication cup and proceeded into the resident's room. In the resident's room, the resident was observed laying flat on his right side on his mattress on the floor. Per the LPN, the resident's care plan interventions included for his mattress on the floor for safety reasons. LPN #605 then proceeded to crawl on the mattress and talk to the resident. She informed the resident she had medication for him and she then proceeded to check placement of the PEG tube by auscultation and by tube residual. The nurse then informed the resident that he needed to roll onto the pillow because she was giving him some medication. She did assist the resident to try to reposition him onto the pillow. She then proceeded to administer 30 cc of water down the resident's PEG tube. The nurse then added about 15 cc's of water and mixed it in the medication. When it was completely mixed, she then administered the medication into the resident's PEG tube. She then added another 15 cc of water into the same cup and emptied it into the resident's PEG tube. She then flushed the PEG tube with another 30 cc of water. After the water was through infusing through the PEG tube, this LPN proceeded to administer to the resident his scheduled tube feeding of 237 cc's of Novasource Renal. She then flushed the peg with 30 cc of water. During the observation of the medication administration, LPN #605 continued to administer Resident #21's medication without his head being elevated 45 degrees per best practice guidelines and failed to keep his head elevated 45 degrees for 30 minutes after the administration of the medication. Interview with LPN #605 on 02/19/20 at 11:30 A.M. verified that she did administer the resident's Page 1 of 6 366463 366463 02/20/2020 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication together and not separately and admitted to administering the medication and the tube feed to the resident while he did not have his head or torso up 45 degrees. She also verified at this time that after administering these medications and the tube feeding, the resident proceeded to lay flat. This Director of Nursing (DON) on 02/19/20 at 3:30 P.M. verified the nurse failed to follow the facility policy on medication administration via peg tube and failed to follow best practice guidelines. Review of the facility policy titled Medication Administration Procedures, dated 07/19 revealed the resident's head should be elevated 30 to 45 degrees and left in that position at least 30 minutes after administration of medication. 366463 Page 2 of 6 366463 02/20/2020 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure pharmacy services were provided to meet the needs of the residents. This affected one (Resident #41) of seven residents reviewed for medication availability. The census was 78. Findings Included: Review of the medical record for Resident #41 revealed admission date of 02/15/19. Diagnoses included cardiomegaly, atrial fibrillation, cardiomyopathy, cardiac pacemaker, aortocoronary bypass graft and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/04/20, revealed the resident had intact cognition. Review of the physician orders for February 2020 revealed the resident had an order for diltiazem CD ER (heart medication) 120 milligram (mg) daily for cardiomegaly. Review of the Medication Administration Record (MAR) 02/2020 revealed diltiazem was not given on 2/15 and 2/16. Review of the progress notes dated 02/15/20 at 2:44 P.M. revealed a call was placed to the pharmacy in regards to Resident #41's Diltiazem 120 mg. There weren't any of the medication in the facility at this time. Interview on 02/18/20 at 11:44 A.M. with Resident #41 stated he went three days without his heart medication over the last weekend. Resident #41 stated he felt like his heart was going back into atrial fibrillation and it just wears him out and makes him cranky. Interview on 02/19/20 at 10:01 A.M. with Licensed Practical Nurse (LPN) #605 revealed Resident #41's diltiazem had run out and there was none in the starter kit. LPN #605 stated all resident medications should be reordered four to five days prior to medications running out. LPN #605 verified Resident #41 did not receive his diltiazem as ordered and was not available for over two days. Interview on 02/19/20 at 3:58 P.M. with the Director of Nursing (DON) verified the nurse should have called the pharmacy on the 02/15/20 to have Resident #41's diltiazem drop- shipped. Review of the facility policy Medication Ordering and Receiving From Pharmacy, dated 12/2017 revealed medications should be reordered five days in advance of need, to assure an adequate supply is on hand. 366463 Page 3 of 6 366463 02/20/2020 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure pureed pulled pork was the proper texture. This had the potential to affect all seven (Resident #6, Resident #16, Resident #19, Resident #59, Resident #79, Resident #80, and Resident #283) of seven residents on a pureed diet. Findings include: Review of the lunch menu on 02/18/20, revealed the main entree was barbeque pulled pork sandwiches. Review of the facility Diet Types report revealed Resident #6, Resident #16, Resident #19, Resident #59, Resident #79, Resident #80, and Resident #283 were ordered pureed texture diets. Observation on 02/18/20 at 10:42 A.M. revealed [NAME] #610 was preparing barbeque pulled pork. [NAME] #610 added broth to the pulled pork and after blending placed it in a pan to be used for service. The puree had visible strings of pulled pork. Upon taste testing the puree, both [NAME] #610 and Surveyor were chewing the pureed pulled pork. Interview with [NAME] #610 at this time revealed she thought the pureed pulled pork was proper texture, but after surveyor intervention, she continued to blend the pureed pork. 366463 Page 4 of 6 366463 02/20/2020 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was served in a sanitary manner. This had the potential to affect 77 of 78 residents receiving food from the kitchen (Resident #21 received nothing by mouth). The facility census was 78 residents. Findings include: Observation of the dinner meal on 02/18/20 starting at 4:22 P.M. revealed the steam table had green beans, lasagna and garlic bread as well as pureed versions of these items ready for service. Trayline started at 4:29 P.M. with [NAME] #601 doing most of the meal plating with [NAME] #602 assisting. At 4:38 P.M. [NAME] #602 was noted to place his hands in the red sanitation bucket and pull out a cloth, then use the cloth to wipe the rims of several plates that had food on them and were ready to be served. At 4:39 P.M., [NAME] #601 was observed placing his gloved hands into the red sanitation bucket, shake off his gloved hands and continue serving food. [NAME] #602 was observed using the sanitation cloth to wipe the rims of plates with food on them again at 4:41 P.M. [NAME] #601 was observed placing his gloved hands in the sanitation bucket and continuing to serve food at 4:43 P.M., 4:49 P.M. and 5:17 P.M. An interview was conducted on 02/18/20 at 5:21 P.M. with [NAME] #601. [NAME] #601 verified he placed his gloved hands into the sanitizer bucket as he did not want to get the plates dirty and stated he just needed to wipe them off, it was only [sanitizing] solution. An interview was conducted on 02/18/20 at 5:23 P.M. with [NAME] #602. [NAME] #602 verified he used the sanitation cloth to wipe the rims of plates that had food on them and were ready for service and stated the sanitizer was food safe. Interview on 02/18/20 at 5:25 P.M. with Corporate Registered Dietitian (CRD) #603 verified the above observations were not indicative of appropriate glove or sanitizing solution usage. CRD #603 confirmed the sanitizing solution was not food safe. Review of a policy on cleaning cloths (no date) revealed cleaning cloths were used with sanitizer and were not left in one's hand, in the bucket or on work surfaces. Review of material safety data sheet (MSDS) information for Oasis 146 Multi-Quat Liquid Sanitizer, issued 04/11/19 revealed for product at use dilution, wash hands thoroughly after handling. 366463 Page 5 of 6 366463 02/20/2020 Avenue at Wooster 1700 East Smithville Western Road Wooster, OH 44691

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure water temperatures were maintained within safe parameters. This affected three (Resident #31, Resident #44, and Resident #81) of eight residents whose bathroom water temperatures were tested. Findings include: 1. Observation on 02/20/20 at 3:05 P.M. of Resident #81's bathroom sink water temperature with Licensed Practical Nurse (LPN) #100 testing the temperature, revealed the water temperature was 130.6 degrees Fahrenheit (F). Interview with LPN #100 at this time confirmed the temperature. 2. Observation on 02/02/20 at 3:10 P.M. of Resident #31s bathroom sink water temperature, tested by LPN #100, revealed the temperature was 125.4 degrees F. Interview with LPN #100 at this time confirmed the temperature. 3. Observation on 02/20/20 at 3:14 P.M. of Resident #44's bathroom sink water temperature, tested by LPN #100, revealed the temperature was 128.7 degrees F. Interview with LPN #100 at this time confirmed the temperature. Review of the facility Water Temperature Checks since 12/02/19 through 02/18/20, revealed water temperatures are randomly tested on ce a week, and were within safe parameters. Interview on 02/20/20 at 4:01 P.M. with Maintenance Supervisor #101 revealed he tests water temperatures weekly in the morning and has the boiler on the water heater at 140 degrees F. Maintenance Supervisor #101 was unaware that the above water temperatures were high. Review of the water temperature guidance for electronic maintenance system (no date) revealed patient rooms were to have water temperatures between 105 degrees F and 115 degrees F or as specified by state requirements. 366463 Page 6 of 6